Provider Demographics
NPI:1942535422
Name:GREEN, DIANE (LMHC)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6611 GULTON CT NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4407
Mailing Address - Country:US
Mailing Address - Phone:505-296-3965
Mailing Address - Fax:505-323-9430
Practice Address - Street 1:6611 GULTON CT NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4407
Practice Address - Country:US
Practice Address - Phone:505-296-3965
Practice Address - Fax:505-323-9430
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-16
Last Update Date:2009-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMT-0125591101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMM1919Medicaid